Provider Demographics
NPI:1316282510
Name:MARTIN K. COONEN, DDS PC
Entity type:Organization
Organization Name:MARTIN K. COONEN, DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:COONEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-442-3190
Mailing Address - Street 1:64 MEDICAL PARK DR STE 1
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-4903
Mailing Address - Country:US
Mailing Address - Phone:406-442-3190
Mailing Address - Fax:
Practice Address - Street 1:64 MEDICAL PARK DR STE 1
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-4903
Practice Address - Country:US
Practice Address - Phone:406-442-3190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-29
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2313122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000124618Medicaid
MT0000258063Medicaid